Starting Date:
Fall (August)	Spring (January)	Summer (May)	Year
Full-Time	Part-Time	Degree Seeking	Certification Only
Non-Degree
Track
Reading		Special Education

Personal Information
First Name:
Middle Name:
Last Name:
Maiden Name:
Mailing Address:
City:
Province/State:
Zip:
Home Telephone:	( )-
Email:
Citizenship:	U.S. Other (Designate Country)
Do you identify yourself as a person of Hispanic/Latino origin? Yes  No
Please indicate your race. Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Birthdate:	month day year
Soc. Sec. No:
Church Affiliation/Denomination:
How did you hear about our program?
Education Background
Certification area
Name of College/University
Graduation Date	month year
Degree Earned
Major
Minor
GPA
Name of College/University
Graduation Date	month year
Degree Earned
Major
Minor
GPA
Name of College/University
Graduation Date	month year
Degree Earned
Major
Minor
GPA
Graduate
Name of College/University
Graduation Date	month year
Degree Earned
Major
Minor
GPA
If no degree earned,specify amount of work completed and your major
Have you attended other colleges for graduate work?	Yes No
Employment
Are you presently employed?	Yes No
Job Title/Position
Employer/Organization
Address
Telephone & Area Code:	( )-
Work Fax #:	( )-
Do you intend to continue your employment should you be admitted the program? Yes No
Ask two people who are familiar with your previous academic or professional work to complete and return the recommendation form for the Master of Education. List the persons who will be completing the reports. Recommendation Form
I affirm that the information I have provided on this application form and all other admission application materials are complete, accurate, and true to the best of my knowledge. I understand that furnishing false or incomplete information on any part of this admission application material may result in cancellation of admission or registration, or both.
Signature
Date